Exercises & Physical Techniques in the Third Stage of Labour - PMC Articles & Guidelines

Important Clarification First

PMC Articles Found

1. Breathing Techniques During Labor - A Multinational Narrative Review

• Lamaze "Third Stage" breathing: Breathe in and out rapidly through the mouth - the "hee-hee-hoo" cleansing breath pattern
• Cicek et al. 2017: shallow, accelerated mouth breathing with "hee-hee-hoo" rhythm during transition
• Almeida et al. 2005 (Read/Lamaze protocol): pressure breathing while bearing down during expulsion
• Benefits reported: pain reduction, shorter labour duration, less perineal trauma

2. Physical Therapy Assistance in Labor - Systematic Review & Meta-Analysis

• Breathing exercises (diaphragmatic, sigh, timed expiration)
• Pursed lip respiratory exercises during the expulsion phase
• Vocalization techniques with low-pitched sounds during pushing
• Pelvic exercises and perineal relaxation
• TENS, massage, mobilization, myofascial release, and kinetic functional exercises

3. Effectiveness of Breathing Exercises on Duration of Labour - Systematic Review & Meta-Analysis

• Deep abdominal breathing + breath-holding push technique during expulsion
• "Push the baby downward while holding breath or breathing out slowly from the mouth"
• Spontaneous pushing + perineal massage significantly shortened second-stage duration

4. Pushing/Bearing Down Methods for the Second Stage of Labour (Cochrane)

• Directed (Valsalva) pushing: deep breath, hold, sustained bearing down
• Spontaneous pushing: follow instincts, push 3-5 times per contraction with open glottis
• Evidence favors spontaneous pushing over directed for reducing perineal trauma

Clinical Guidelines for Obstetric "Third Stage" (Placental Delivery)

• Upright or supported squatting positions
• Skin-to-skin contact (stimulates natural oxytocin)
• Early breastfeeding
• Minimizing interruptions and keeping the environment calm and warm

Summary

• Breathing techniques during expulsion - PMC9822559 and PMC9999308 are ideal
• Physiotherapy across all labour stages - PMC11804556 (2025 systematic review) is the best current resource
• Active vs. physiological management protocols - see WHO/NICE/ACNM guidelines above

Evidence for Exercises Across All Stages of Labour

Overview

FIRST STAGE OF LABOUR

1. Birthing Ball (Swiss Ball) Exercises - Most Studied Intervention

• Pain reduced by ~20% at 4 cm and 8 cm dilation (p<0.001)
• First stage of labour shortened by >2 hours (MD -130.12 min, p<0.001)
• Caesarean section rates significantly reduced (RR 0.55, p=0.007)
• No significant effect on the second stage duration
• Conclusion: "BB exercises significantly reduced cesarean section rates, alleviated labor pain, and shortened the first stage of labor - supporting their use as a safe and effective non-pharmacological intervention."

• Labour pain decreased by 1.70 points on VAS (MD -1.70; 95% CI -2.20 to -1.20)
• Effective for women labouring without an epidural

2. Upright Positions & Ambulation (Walking, Standing, Kneeling)

• First stage shortened by ~82 minutes (MD -1.36 hours; 95% CI -2.22 to -0.51)
• Reduced caesarean section risk (RR 0.71; 95% CI 0.54-0.94)
• Reduced epidural use (RR 0.81; 95% CI 0.66-0.99)
• Fewer NICU admissions (RR 0.20 in one trial)
• Conclusion: "Women in low-risk labour should be informed of the benefits of upright positions, and encouraged and assisted to use them."

3. Physical Therapy (Comprehensive Protocols)

• Increased vaginal deliveries (RR 1.10; 95% CI 1.04-1.17) - high certainty
• Reduced caesarean sections (RR 0.52; 95% CI 0.35-0.76) - high certainty
• First stage shortened by 99 min (MD -99.01 min; 95% CI -153.35 to -44.66)
• Second stage shortened by 11 min (MD -11.29 min; 95% CI -18.94 to -3.64)
• Reduced perineal lacerations (RR 0.49; 95% CI 0.25-0.96)
• Reduced pain intensity and maternal anxiety
• Techniques included: breathing exercises, birthing ball, TENS, pelvic mobilization, massage, myofascial release, and ambulation

SECOND STAGE OF LABOUR

4. Breathing Exercises - Duration of Second Stage

• Breathing exercise significantly shortened the second stage compared to control
• Secondary benefits: reduced anxiety, improved APGAR scores
• Techniques studied: diaphragmatic breathing, Lamaze (hee-hee-hoo), Valsalva vs. spontaneous pushing, pursed lip breathing
• Conclusion: "Breathing exercise is a beneficial preventive intervention in shortening the duration of the second stage of labour."

5. Upright Position in Second Stage (with Epidural)

• Little or no difference in operative birth rates overall (low-certainty evidence due to heterogeneity)
• Upright position associated with higher postpartum haemorrhage risk in the largest trial (BUMPES trial) - an important safety caveat
• Positions studied: sitting, kneeling, lateral vs. recumbent

6. Pushing Techniques & Mind-Body Exercises

• Hypnosis: significant pain reduction (SMD -1.45, large effect size)
• Mindfulness: significant pain reduction (SMD -1.22) + reduced caesarean rates (RR 0.46) + reduced fear of childbirth
• All categories associated with shorter labour duration
• Breathing skills and muscle relaxation are the most clinically accessible interventions

THIRD STAGE OF LABOUR

7. Breathing Techniques (Lamaze Framework)

• Cicek et al. protocol: breathe rapidly in and out through the mouth with "hee-hee-hoo" cleansing breath
• Almeida et al. protocol: pressure breathing while bearing down during expulsion

8. Physical Management Strategies

• Upright or squatting positions to assist placental descent
• Skin-to-skin contact + early breastfeeding (stimulates endogenous oxytocin)
• Warm, calm, low-stimulus environment
• Uterine/fundal massage (only in absence of prophylactic oxytocin per WHO)

Summary Table

Postoperative Role of Physiotherapy in Stress Urinary Incontinence - Recent Evidence

What "Postoperative" Means in SUI

1. After SUI surgery in women - mid-urethral sling (TVT/TOT), Burch colposuspension, or periurethral bulking agents - where residual leakage or incomplete cure requires rehabilitation
2. After radical prostatectomy in men - the most studied postoperative SUI model, with the largest RCT evidence base

SECTION 1 - WOMEN WITH SUI: Conservative Physiotherapy Evidence

1. Cochrane Overview of All Conservative Interventions (2022)

2. Network Meta-Analysis: Best Conservative Treatment for Women (2024)

1. Electrical stimulation - SUCRA 95.9% (best)
2. Biofeedback + electrical stimulation - SUCRA 84.9%
3. Radiofrequency - SUCRA 77.5%
4. Biofeedback alone - SUCRA 57.8%
5. Magnetic stimulation - SUCRA 45.3%
6. PFMT alone - SUCRA 38.4%
7. Er:YAG laser - SUCRA 37.4%

1. Er:YAG laser - SUCRA 97.5%
2. Biofeedback + electrical stimulation - SUCRA 83.4%
3. Biofeedback alone - SUCRA 67.0%
4. PFMT alone - SUCRA 43.0%

SECTION 2 - POST-PROSTATECTOMY SUI IN MEN

3. Cochrane Review: Conservative Interventions After Prostate Surgery (2023)

• PFMT + biofeedback vs. no treatment: May result in greater subjective cure at 6-12 months (low-certainty evidence; 1 study, n=102)
• Combination conservative treatments: Little difference vs. control at 6-12 months (moderate-certainty evidence)
• Electrical/magnetic stimulation: Inconclusive evidence vs. sham (low-certainty)
• Key limitation: Most studies were high risk of bias; more rigorous RCTs needed
• Practical note: Even with modest evidence, conservative management is universally recommended before surgical intervention

4. Supervised vs. Unsupervised PFMT After Radical Prostatectomy (2022)

• PFMT vs. no PFMT: 12-25% higher remission at 3, 3-6, and 6+ months post-surgery
• Supervised PFMT had clear benefit in the first 6 months
• Unsupervised PFMT had similar effects as NO PFMT - a critically important finding
• Biofeedback added benefit only in the first 3 months post-surgery
• Clinical implication: All PFMT programs must be physiotherapist-supervised, especially in the first 6 months

5. PFMT Meta-Analysis: Timing and Duration of Benefit (2024)

6. Full Treatment Options Review for Post-Prostatectomy Incontinence (2022)

SECTION 3 - Physiotherapy Techniques Used Postoperatively

A. Pelvic Floor Muscle Training (PFMT)

• Fast-twitch contractions: 10 repetitions x 3 sets (for stress response)
• Slow-twitch contractions: hold 10 sec x 10 reps x 3 sets (for endurance)
• Supervision is mandatory - unsupervised PFMT is no better than no PFMT (Baumann 2022)
• Frequency: daily; duration: minimum 3-6 months postoperatively

B. Biofeedback-Assisted PFMT

• Surface EMG or manometric pressure biofeedback
• Teaches correct muscle activation (avoids accessory muscle substitution)
• Most beneficial in first 3 months postoperatively

C. Electrical Stimulation (ES)

• Intravaginal/intrarectal or surface electrode stimulation
• Frequency 10-50 Hz for stress incontinence (higher frequency for urgency)
• SUCRA ranking: best single modality for ICIQ-UI symptom score improvement

D. Combined Biofeedback + Electrical Stimulation

• Ranked best overall in the 2024 network meta-analysis (Li et al.)
• Addresses both sensory awareness and motor recruitment simultaneously

E. Magnetic Stimulation (ExMI - Extracorporeal)

• Non-invasive; no probe insertion required
• Growing evidence base, especially for patients unable to tolerate internal probes

F. Bladder Training

• Timed voiding and urge suppression techniques
• Particularly useful when mixed incontinence is present postoperatively

Summary of Evidence Levels